DH206: Pharmacology CH 19:Respiratory Lisa Mayo, RDH, BSDH Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved

DH206: PharmacologyCH 19:RespiratoryLisa Mayo, RDH, BSDH

Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

2Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Respiratory Drugs

Diseases treated with respiratory drugs

1. Asthma

2. COPD: emphysema, bronchitis

3. Upper respiratory infections

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Class of Resp. DiseasesClinic III

Location Acute Chronic

Upper Resp RhinitisSinusitisPharyngitis/TonsillitisFlu

Allergic rhinitis

Lower Resp Acute bronchitisPneumonia

TBAsthmaCOPD Cystic bronchitis


Respiratory DrugsAsthma

• Considered an inflammatory disease• Chronic lung disease• Drug therapy aimed at relieving broncho-spasm & inflammation

Airway ObstructionCaused By:

Notations

Bronchoconstriction Loss lung elasticityMediated through ß-2 receptors

Inflammation Results from mucous productionMediators are histamine, prostaglandins, leukotrienes, cytokines

Loss lung elasticity Results from air sac enlargementTx is difficult (long-term, high dose meds)


2007 Guidelines for Management of Asthma

ASTHMA TYPE

THERAPY 1st LINE DRUGS 2nd LINE DRUGS

Intermittent No meds Albuterol prn (B2-agonist) ------------

Mild Daily meds Inhaled corticosteroid Leukotriene modifierMethylxanthineMast cell stabilizer

Moderate Daily meds Inhaled corticosteroid OR LABA Leukotriene modifierMethylxanthine

Severe Daily meds Inhaled corticosteroid + LABA Leukotriene modifierMethylxanthine

USE THIS INSTEAD P.221, TABLE 19-1EASIER TO UNDERSTAND THIS WAY


Respiratory Drugs2007 Guidelines for Diagnosis & Management of Asthma• Number & frequency of meds ↑ as severity of asthma worsens• Beginning therapy: start with highest recommendations & stair-

step down as patient needs• Inhaled meds preferred agents

• High concentrations of drug delivered to airways with few systemic side effects

• Severe asthma attacks

1) ß-2 agonist preferred agent (EPI)

2) Corticosteroid tablets to relieve inflammation

3) Oxygen


Respiratory Drugs

Drug Delivery

1. Systemic: oral, parental

2. Inhaled: shorter onset, fewer side effects

1) Nebulizer

2) Dry powder inhaler

3) Metered-dose inhalers (most common delivery system)


Respiratory Drugs

Asthma Medications: 2 classes of medications

1. Quick-relief medications•Reliever/Acute rescue drugs

2. Long-term medications•Control, Maintenance meds•Taken daily•Most have anti-inflammatory effects


Respiratory DrugsAsthma Medications

• 2 classes of medications


2. Long-term medications (mild, moderate, severe asthma & COPD)•Control, Maintenance meds•Taken daily•Most have anti-inflammatory effects


Quick-Relief MedsProduce bronchodilationProtype: albuterol(Ventolin, Proventil)Tx acute symptomsNot used for daily preventionPatients need to rinse after use (NBQ)

DRUG CATEGORIES

MECHANISM OF ACTION USES

Beta-Adrenergic Agents (Sympathomimetic Agents)

Stimulate beta-2 adrenergic receptors prn

Anticholinergics Block cholinergic (muscarinic) receptors COPD

Systemic corticosteroids

Emergencies Asthma or COPD


Quick-Relief Meds

1. Beta-Adrenergic Agents (Sympathomimetic Agents)

ß-2 Adrenergic DrugsAlbuterol(Proventil, Ventolin)

Metaproterenol(Alupent)

Levalbuterol(Xopenex)

p. 224


Quick-Relief Meds

1. Beta-Adrenergic Agents (Sympathomimetic Agents)• NON-SELECTIVE (stimulate β-1 & β-2)o2 drugs: Epi & isopreterenol(Isuprel)oWhen used to tx asthma – will also ↑ heart rate

• SELECTIVEoSelective beta-2 drugs are BEST: bronchodilatorsoFewer effects on beta-1



β-agonist stimulates enzyme AC to ↑ cAMP levels – results in dilation


Can be difficult for kids to use: use a separate connector – can decrease amt of drug administered


NBQ

After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth?

a. Ipratropiumb. Cromlyn sodiumc. Metaproterenold. Theophylline


NBQ

After which of the following drugs used to treat asthma should the dental hygienist instruct the patient to rinse the mouth?

a. Ipratropiumb. Cromlyn sodiumc. Metaproterenold. Theophylline


NBQ

Which of the following drugs is the drug of choice for the quick relief of bronchospasm?

a. Albuterolb. Ipratropiumc. Hydrocortisoned. Salmeterol


NBQ

Which of the following drugs is the drug of choice for the quick relief of bronchospasm?

a. Albuterolb. Ipratropiumc. Hydrocortisoned. Salmeterol


NBQ

Which of the following drugs is classified as a β2-agonist bronchodilator?

a. Albuterolb. Ipratropiumc. Hydrocortisoned. Montelukast


NBQ

Which of the following drugs is classified as a β2-agonist bronchodilator?

a. Albuterolb. Ipratropiumc. Hydrocortisoned. Montelukast


Quick-Relief Drugs

2. Anticholinergic Agents: used for tx COPD, not asthma

DRUG NOTATIONS

Ipratropium bromideHFA(Atrovent) PROTYPENasal spray: useful for rhinitis

Ipratropium bromide + albuterol sulfate(Combivent)

Tiotropium bromide(Spiriva) LONG-TERM, NOT SHORT ACTING FOR TX COPD

p.226


Quick-Relief Drugs2. Anticholinergic Agents

• Action: Inhibit ACH receptors on smooth muscle= bronchodilation

• Protype: ipratropium bromide(Atrovent)• Adverse effects

• Xerostomia• Taste alteration• Instruct pt to rinse mouth after each inhalation (NBQ)


Muscarinic antagonists block effects of ACH & PANS – leads to bronchodilation


Quick-Relief Drugs

3. Systemic corticosteroids• Used when asthma cannot be controlled by bronchodilators alone

• Short-term• Decrease inflammation• Systemic delivery = acute attacks

Inhaled delivery = chronic, long-term therapy


Respiratory DrugsAsthma Medications

• 2 classes of medications


2. Long-term medications•Control, Maintenance meds•Taken daily•Most have anti-inflammatory effects


Long-Term Meds

Inhaled corticosteroids Asthma

Selective long-acting ß-2 Agonists (LABA)

Asthma or COPD(never used as stand-along therapy, always in combo)

Methylxanthines COPDIV for status asthmaticus

Mast cell stabilizers Asthma

Leukotrienes Modifiers Asthma

Immunomodulators Asthma


Long-Term Meds









Long-Term Meds

Inhaled corticosteroids• Drug of choice for persistent asthma• 1st line long-term therapy• Potent & effective anti-inflammatory agents• Decrease airway hyper-reactivity & swelling• Rinse mouth after inhaler use (NBQ)


Long-Term Meds

Inhaled corticosteroids

Inhaled CorticosteroidsBeclomethasone dipropionate(Beclovent, Vanceril)

Budesonide(Pulmicort)

Flumisolide(Aerobid)

Fluticasone(Flovent, Advair)

Mometasone(Asmanex)

Triamcinolone(Azmacort)


Long-Term Meds









Long-Term Meds

Selective long-acting ß-2 Agonists (LABA)• Bronchodilators• Not used alone – usually in combo w/corticosteroids• Black box: NOT to be used as stand alone tx – increase risk

of asthma-related deaths

Selective long-acting ß-2 Agonists

Salmeterol(Serevent)

Formoterol(Foradil)


Long-Term Meds









Long-Term MedsMethylxanthines

• Bronchodilators that relax the airway smooth muscle• COPD• Many drug interactions

• Erythromycin• Clarithromycin• Caffeine: can cause mild bronchodilation in patients with asthma

(100mg which is in a cup of coffee)

Methylxanthines

Theophylline(Slo-Phyllin),TheoDur, Theo-24)

Aminophylline(norphyl)


Theophylline inhibits enzyme PDE, slows inactivation of cAMP, leads to dilation

Theophylline antagonizes adenosine (bronchoconstrictior)


Long-Term Meds









Long-Term Meds

Mast cell stabilizers p.225, books calls this category cromolyn

• Inhibit release of histamine (decrease inflammation)

Mast Cell Stabilizers

Cromolyn sodium(Intal)

Nedocromil(Tilade)


Long-Term Meds









Long-Term Meds

Leukotrienes Modifiers• Block activity of arachidonic acid derivatives = decrease

inflammation • P-450 enzyme induction • Drug interactions

• Aspirin• Erythromycin• Increase effect Warfarin

Leukotriene Modifiers

Zafirukast(Accolate)

Montelukast(Singular)

Zileutron(Zyflo)


Zileutron(Zoflo)

zafirlukast(Accolate),

montelukast(Singular)


Long-Term Meds









Long-Term Meds

Immunomodulators• Prevent IgE from binding to mast cells

Immunomodulators

Omalizumab(Xolair)


omalizumab(Xolair)

omalizumab(Xolair)Binds to receptors so allergen cannot


NBQ

Which of the following drugs is preferred for long-term control of asthma?

a. B-1 agonistb. B-2 agonistc. Inhaled corticosteroidd. Oral corticosteroids


NBQ

Which of the following drugs is preferred for long-term control of asthma?

a. B-1 agonistb. B-2 agonistc. Inhaled corticosteroidd. Oral corticosteroids


NBQ

Which of the following drugs is used to control mild persistent asthma?

a. Albuterolb. Ipratropiumc. Inhaled beclomethasoned. Salmeterol


NBQ

Which of the following drugs is used to control mild persistent asthma?

a. Albuterolb. Ipratropiumc. Inhaled beclomethasoned. Salmeterol



DH Considerations

• Aspirin & NSAIDs contraindicated in asthmatic patients (can lead to bronchospasm)

• Anticholinergic side effects• Consult MD in SEVERE asthma cases• Inhalers brought to appts• Systemic corticosteroids – pt may need increase dose morning of

apt• Inhalers: advise pt to rinse after to avoid dry mouth & oral

candidiasis


Agents used to manage upper respiratory tract infections

Agents used to manage upper respiratory tract infections1) Nasal Decongestants2) Expectorants & Mucolytics3) Antitussives



1) Nasal Decongestants• Constrict blood vessels in nasal mucous membranes• Chronic use may result in rebound swelling and congestion• Book correction: not all nasal decongestants are α-agonists

(p.226)• Remember: Patanase is a nasal antihistamine, not a

decongestant



Nasal Decongestants

phenylephrine (Neo-Synephrine, Sinex, Allerest) α-agonist

pseudoephedrine(Sudafed, Sucrets, Actifed) α-agonist

Beclomethasone(Beconase,Vancenase) Corticosteroid Nasal spray

Mometasone(Nasonex) Corticosteroid Nasal spray

Fluticasone(Flonase) Corticosteroid Nasal spray

Budesonide(Rhinocort) Corticosteroid Nasal spray

Flunisolide(Nasalide) Corticosteroid Nasal spray

Cromolyn(Nasalcrom) OTC nasal spray

Nedocromil(Tiladle) Nasal spray for asthma & rhinitis


NBQ

Which of the following types of agents are nasal decongestants?

a. B-1 agonistb. B-2 blockersc. Alpha-1 agonistd. Alpha-2 blockers


NBQ

Which of the following types of agents are nasal decongestants?

a. B-1 agonistb. B-2 blockersc. Alpha-1 agonistd. Alpha-2 blockers



2) Expectorants & Mucolytics• Mucolytics

• Promote removal of exudate or mucus from respiratory passages• Liquefying & decrease viscosity of mucus• Acetylcysteine(Mucosil): Useful in cystic fibrosis

• Expectorants• Drugs that facilitate the removal of thickened mucus secretions from

the lungs• Action: ↑ bronchial = liquefy mucus• Guaifenesin(Mucinex) most popular




3) Antitussives: agents used to suppress coughDrugs Notations

Opioids: (Codeine, Hydrocodone, Hydromorphone)

Narcotic opioidAvoid in asthmatic (cause respiratory depression)

Dextromethorphan(Robitussin, Vicks)

Non-narcoticMany OTC products contain

Benzonatate(Tessalon) Non-narcotic


NBQ

Which of the following terms defines “suppressing a cough?”a. Expectorantb. Antitussivec. Antihistamined. Antiasthma


NBQ

Which of the following terms defines “suppressing a cough?”a. Expectorantb. Antitussivec. Antihistamined. Antiasthma


NBQ

Which of the following drugs MAY be contraindicated in asthmatics?

a. Aspirinb. Acetaminophenc. Vitamin Cd. Folic acid


NBQ

Which of the following drugs MAY be contraindicated in asthmatics?

a. Aspirinb. Acetaminophenc. Vitamin Cd. Folic acid


Documents

DH206: Pharmacology CH 19:Respiratory Lisa Mayo, RDH, BSDH Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved